Overworked nurses ration patient care

01:33, May 27 2014

New Zealand hospitals are under-staffed, under-resourced and at times unsafe, nurses claim. In the fourth article of The Press health series, OLIVIA CARVILLE reports on care rationing - a hidden secret in our hospitals.

Every day nurses across New Zealand are being forced to make impossible choices.

They are unwillingly leaving patients lying in filth, ignoring call bells and skipping vital recordings.

The Press has heard horror stories of critically ill patients who have broken bones falling from hospital beds in an attempt to get to the toilet and others who have suffered serious infections after their surgical dressings have not been changed for days.

It may be unknown to the general public, but care rationing is a tragic and undeniable reality in New Zealand hospitals.

The looming global financial health crisis and rising care demands is forcing the Government to try and cut costs in the sector, yet at the same time it's increasing its expectations of district health boards (DHBs).


Over-worked nurses are having to decide what care is critical for patient survival and what can be left undone, the New Zealand Nurses Organisation (NZNO) says.

Lack of so-called basic health care can lead to infected surgical wounds, bed sores, blood clots and many other life threatening issues.

Kiwi nurses are intentionally rationing care because they are too busy operating in "flat-out rescue mode" all the time, Massey University's Bachelor of Nursing head Dr Bert Teekman says.

On an average day in a hospital ward, one nurse would be responsible for up to seven patients, with some who are bed-bound and completely dependent.

While this may have been a manageable task 20 years ago, health reforms in the 1990s saw length of hospital procedure stays shorten, which meant patient acuity climbed significantly, Teekman says.

More complex cases that would have usually been admitted to high dependency units were also placed in ordinary wards now - all of which has added to the everyday nurses' workload.

"What happens now has never happened before. Our whole clinical scene has changed dramatically and it's a lot harder on today's nursing staff."

For the first time in New Zealand history, care rationing is now being measured in 12 district health boards through the Safe Staffing and Healthy Workplaces Unit (SSHW).

Early research shows care rationing is evident in all 12 DHBs, and in some cases at alarming levels.

At the same time, serious adverse events that cause either patient harm or death have climbed 140 per cent in New Zealand hospitals since they were first recorded in 2006/07.

The Health Quality and Safety Commission, which collates the data, has pinned this massive jump on improved reporting of the events rather than an increase in their frequency.

However, some believe the mounting pressures on the health sector are also to blame.

Ministry of Health chief nurse Jane O'Malley says an increase in hospital admissions of people who are older and sicker and a significant reduction in hospital length of stay mean "nurses must deliver more complex care in a shorter timeframe".

Nurses constantly make choices about what activities they do during their shift, particularly if that shift is unpredictably busy with high admission rates, a medical emergency or unusually high staff sickness, she says.

Nurse staffing across all DHBs is continuing to grow - jumping from 18,325 in 2008 to 21,598 in 2014.

Over the same period of time, our ageing population and growing chronic disease epidemics have seen patient admission numbers overtake the growth in nursing positions four-fold, according to NZNO.

The number of admitted patients nationwide increased by 16 per cent between June 2010 and March 2013.

The figures highlight that care rationing is being caused by "unsafe levels of staffing", NZNO associate professional services manager Hilary Graham-Smith says.

Every day nurses were being forced to make decisions about what they could and could not do in an eight hour shift.

"Care rationing is a moral and ethical dilemma for nurses. It causes them significant distress and can lead to burnout and nurses exiting the profession," she says.

Teekman, who spent 18 months observing nurses in New Zealand hospitals for part of a research paper, says he saw nurses continuously operating in "flat-out rescue mode".

Daily, he found they were so busy helping doctors, organising medications, making phone calls and filling out paperwork that they spent only three hours of their shift actually with patients.

Despite the Government pouring more money into healthcare every year, "the reality is care rationing won't disappear overnight".


One North Island nurse, who spoke to The Press on the condition of anonymity, says all New Zealand hospitals are understaffed.

"As a nurse, you could have the best will in the world, but you just simply cannot do it all."

Nurses regularly drop care such as answering call bells, showering patients, turning those who were bed-bound and taking vital signs, all of which can lead to pressure ulcers, blood clots, falls and pneumonia, she says.

Some days her colleagues even fail to deliver pain medication to post-surgery patients and leave others in soiled beds.

"This is distressing for patients and relatives and it makes nurses feel dreadful," she says.

"Families don't always see how run off their feet nurses can be. We are the ones who cop the flak from the families even though it's through no fault of our own."

The nurse, who has worked in a public hospital for more than eight years, believes the problem has "definitely gotten worse" in her time.

"Things we used to consider basic nursing care, such as hygiene, will become harder and harder to do and we will probably see an increase in infections and an increase in falls," she says.

Long-time registered nurse Erin Kennedy recently wrote a blog for NZNO on the issue of care rationing.

She wrote about nurses fearing they would lose their jobs if they spoke out about a working environment that was "understaffed, under-resourced and, at times, unsafe".

"How often have you shuddered at a horror story told in the tearoom, or heard a colleague declare that 'I wouldn't let anyone from my family stay on that ward... it's just not safe'. Surely the public has a right to know what is happening in our hospitals," she wrote.

In February this year, 300 Dunedin nurses attended a stop-work meeting because "they were genuinely concerned that they were so understaffed they were putting patient safety at risk".

A nurse who attended the meeting spoke to The Press on the condition of anonymity. She says the "general consensus is we are so stretched with resources that patient care is being compromised".

One particularly harrowing example of care rationing in Dunedin Hospital's Neonatal Intensive Care Unit was exposed at the meeting.

Nurses caring for premature babies spoke about being faced with unbearable decisions over which babies to monitor and which to leave to potentially go blind.

Premature babies require 24/7 nursing care to ensure they receive steady supplemental oxygen levels to avoid damaging the partially formed blood vessels in their eyes.

"The nurses in the unit were saying that they didn't have enough staff to provide one-on-one care and that they were literally looking at two prem babies and having to choose between which baby to monitor and which baby to leave to maybe go blind," she says.

Another anonymous nurse who works in an acute theatre setting told The Press her ward recently received an unusually high number of elderly patients with broken femurs or femoral neck fractures.

They all needed surgery within 48 hours so they were all starved upon arrival, however they didn't all get the operation, she says.

"So what happened was, these elderly patients were being starved every day and at 10pm at night when their surgery hadn't happened, they were allowed to have a sandwich or something, and then starved again from 2am in the hope of surgery the next day."


In response to the nurses' reports about soiled beds and patient dressings not being changed, Ministry of Health chief nurse O'Malley says there is a "big difference between prioritising work and failure to provide essential care".

Nurses are always professionally responsible and will be held accountable for their actions, she says.

The quality and safety of the health sector is being closely monitored by a range of agencies, O'Malley says.

Improvement initiatives are underway to ensure workload is well matched to demand, such as the Care Capacity Demand Management (CCDM) programme, developed by the SSHW unit, she says.

SSHW director Lisa Skeet says the unit, a collaboration between unions and DHBs, has kickstarted the CCDM system to measure whether the health sector was actually meeting patient demand back in 2009.

The unit is now actively working with 12 DHBs, looking into roster patterns, staff levels, patient turnover and missed care.

So far, the programme has proved care rationing is evident in all 12 DHBs, she says.

National Ministry of Health targets may show patients now have shorter waits in emergency departments, faster cancer treatments and more elective operations, however New Zealand Medical Association chair Dr Mark Peterson says clinicians "actually do have to make some hard decisions at times and governments don't like to admit that".

"Nobody likes to use the terminology 'care rationing', but that's exactly what it is."

Government pressures and financial constraints are pushing DHB management to enforce more expectations on nurses and doctors, he says.

"This actually is an issue we need to look at in terms of patient safety. There is no point caring for patients and trying to increase the number of patients cared for if the care you are giving them is substandard," he says.

Christchurch Hospital emergency department specialist Dr Mike Ardagh says staff ration care because they have to.

Clinicians tend to prioritise care into four boxes, he says.

First are the care elements that will preserve life, second is trying to preserve limb, third is aiming to provide comfort and fourth, are the other things that enhance care, such as discharge information and hygiene.

The third and fourth boxes are under threat because, after all, saving one person's life is more important than helping three others take a shower, he says.


Care rationing is usually a term discussed in political science lectures.

At the coalface, care rationing can be seen on hospital wards when over- worked nurses can no longer provide the full level of care to their patients.

But, at a macro level, the Government rations health care via controlled distribution, whether through national budgeting, waiting lists or imposing limitations on medical services.

In its most simplest form, rationing refers to the mechanisms used to allocate resources.

It was most famously seen during World War II when butter, sugar, gasoline and other basics were rationed to the masses to ensure soldiers had food and support while they fought overseas.

Care rationing is necessary in health sectors all over the world as they face increasing demands and tighter health budgets.

The Press